Health Insurance Matters: Problems at the Pharmacy?

Among the questions that I have been answering these first weeks of January are from readers and clients who learn that one (or more) of their medications are no longer covered on their plan for 2019 that was covered last year. Typically, there will be an alternate medication that is designed to do the same job. If your plan is not covering your medication, you should inquire from the pharmacy or from your plan if you are eligible for a transition refill which can provide you with a temporary 30-day supply of your medication so you can get a new prescription from your provider. A transition refill is typically a one-time, 30-day supply of a drug that you were taking before switching to a different Part D plan (either stand-alone or through a Medicare Advantage Plan), or before your current plan changed its coverage at the start of a new calendar year.

There are some situations where the medication is still on the plan’s formulary (list of covered drugs), but a new restriction or limitation has been added. You would typically receive a letter from your prescription plan advising you that there is now a requirement for prior authorization or step therapy. Prior Authorization will require your doctor to contact the company and justify the reason for the choice of that particular medication. It is not always a cost issue. Some medications are designed for younger aged patients, and the company is concerned with safety. Other times there are less costly alternatives. Step Therapy is a restriction that addresses this. Your provider will not be permitted to prescribe a costly drug if there are less costly alternatives. Once these alternatives have been tried and discounted, then the more expensive drug will be permitted.

Remember: All stand-alone Part D plans and Medicare Advantage Plans that offer drug coverage must provide transition refills in the above cases. When you use your transition fill, your plan must send you a written notice within three business days. The notice will tell you that the supply was temporary and that you should either change to a covered drug or file an exception request with the plan.

New 7 Day Rule for Opioids. Many states have been instituting regulations for control of the use of various pain medications over the past several years. Effective January 1, 2019, Medicare is instituting new opioid prescribing policies that will impact Medicare Part D beneficiaries with a prescription drug benefit and their prescribers…7-day supply limit for opioid naïve patients: Part D plans are expected to limit initial opioid dispensing to a 7-day supply or less. After the 7-day prescription has been filled, then the traditional 30 day at a time supply will resume. It appears that if you have changed Medicare prescription plans (either stand-alone Prescription Drug Plans -PDP’s or Medicare Advantage HMO’s) you will fall into this 7-day situation. Also, if you had not received a (restricted) pain medication in the last 90 days you will be subjected to the new rule.

Pharmacies also have guidance as to the maximum number of specific medications they can dispense in a given month, and the pharmacists are encouraged to telephone doctors to confirm written prescriptions. CVS Caremark instructs their branch pharmacies, “When max quantity limits are exceeded, the claim will reject with the following or similar message: <<75: Prior Authorization Required>>. Pharmacists should reach out to prescribers by phone to communicate the rejection and understand whether the quantity can be reduced within limits, or if a PA will be requested. Confirm correct directions and dose with prescribers if reducing the quantity.

With physicians, pharmacies and insurance companies all working to reduce the misuse of opioids, I trust it will stem the tide of abuse. It is a pity that the people who really need these strong medications will be forced to go through the hoops to obtain the relief then need and deserve.

My thanks to The Medicare Rights Center and CVS Caremark for data used in this article.

Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 27 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail harrythal@aol.com or visit him on the web at www.harrythal.com.